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© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
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© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
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© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
in the clinic
Gastroesophageal reflux disease
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
What causes GERD?
Prolonged exposure to reflux of gastric contents
Transient relaxations of lower esophageal sphincter expose esophagus to stomach acid and contents
Factors that increase exposure
Increased intra-abdominal pressure (obesity, pregnancy)
Decreased esophageal or gastric motility
Xerostomia
Hiatal hernia
Increased esophageal sensitivity may predispose to more severe symptoms or tissue damage
Increased acid production is not an important cause of GERD
Zollinger-Ellison syndrome the rare exception
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
What symptoms and signs should prompt clinicians to consider GERD?
Typical esophageal symptoms
Heartburn
Regurgitation
Atypical esophageal symptoms
Epigastric discomfort
Noncardiac chest pain
Nausea, satiety, dysphagia, globus, eructation, hematemesis
Extraesophageal symptoms
Cough, wheezing
Sore throat, hoarseness
Dental erosions
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
When should clinicians try an empirical therapeutic trial of acid suppression therapy to support a preliminary diagnosis?
When upper GI complaints are vague and symptom questionnaire is suggestive of GERD
Reflux Disease Questionnaire: 12-question instrument
When esophageal & extraesophageal symptoms present
Trial of PPI: take once or twice daily for 1 to 2 weeks
Assure proper dosing and compliance
If only partial improvement occurs, consider twice-daily dosing or switch to another PPI before declaring non-responder
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
When should clinicians consider upper endoscopy in evaluating patients with possible GERD?Indications for EGD in Known or Suspected GERD
Typical GERD symptoms that persist after a PPI trial
Alarm symptoms (dysphagia, bleeding, unexplained iron deficient anemia, weight loss, vomiting, epigastric mass)
Atypical GERD symptoms (epigastric pain, early satiety, food impaction): to exclude other upper GI diseases
Confirm healing after severe erosive esophagitis
Screen for Barrett esophagus in men >50 years with chronic GERD and additional risk factors
Surveillance of known Barrett esophagus
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
What other diagnoses should clinicians consider in patients with suspected GERD?
Esophageal disorders
Cancer (squamous or adenocarcinoma)
Eosinophilic esophagitis
Functional heartburn
Motility disorders (achalasia, spastic disorders, hypotensive lower esophageal sphincter)
Nonreflux esophagitis (infectious, pill- or radiation-induced)
The rumination syndrome
Strictures, webs, or rings
Zenker’s diverticulum
Continued
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
Other gastrointestinal disorders
Biliary colic
Gastritis
Gastroparesis
Hiatal hernia
Nonulcer dyspepsia
Peptic ulcer disease
Nongastrointestinal disorders
Chest wall pain
Coronary artery disease
Oropharyngeal and laryngeal disorders
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
What other lab tests should clinicians consider when the diagnosis is uncertain?
Ambulatory reflux monitoring
Esophageal manometry
For refractory cases
For pre-op testing for anti-reflux surgery
Barium radiography (esophagram &/or upper GI series)
For primary complaint of dysphagia
For pre-op or post-op testing for anti-reflux surgery
Laryngoscopy
Presence of laryngeal erythema, edema, or other abnormalities not specific for GERD
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
Is there any connection between GERD and Helicobacter pylori infection?
Diagnose and manage as separate entities
Both may present with dyspepsia
No reason to test for H. pylori in patients with typical symptoms of heartburn or regurgitation
Patients with H. pylori gastritis may experience increased GERD symptoms even when H. pylori is eradicated
Long-term PPI use may increase risk for atrophic gastritis in patients with undiagnosed H. pylori infection
Routinely checking H. pylori status in patients on long-term PPIs is not recommended
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
When should clinicians consider gastroenterology consultation during the evaluation of GERD?
Typical symptoms do not respond to an empiric PPI trial
Atypical symptoms overlap with those of other esophageal or gastric disorders
Alarm symptoms
High risk of Barrett esophagus and adenocarcinoma
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
CLINICAL BOTTOM LINE: Diagnosis... Empiric diagnosis of GERD is based on
Presence of typical esophageal symptoms
Response to a PPI trial
Use of patient-reported questionnaires
If no response to PPI trial or if symptoms are extraesophageal or atypical: consider other disease possibilities
Consider EGD when alarm signs are present (dysphagia, bleeding, weight loss, vomiting or epigastric mass)
Don’t use barium radiography or laryngoscopy for GERD Dx
Reserve other tests for refractory or complex cases
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
What is the role of dietary modification in the treatment of GERD?
Dietary modifications may improve symptoms or reduce complications, but evidence isn’t strong
Some foods may lower LES tone (carminatives)
Other foods may irritate inflamed esophageal mucosa (citrus)
Patients may report improvement when avoiding particular substances
May control uncomplicated GERD without medical therapy
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
Are behavioral interventions effective in the treatment of GERD?
Weight loss
Smoking cessation
Elevating head by 6-8 inches when in bed
Avoiding meals in the last 2-3 hours before bed
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
Which medications cause or exacerbate GERD, and how should clinicians counsel patients regarding their use?
Medications that exacerbate GERD
By decreasing LES pressure and/or slowing esophageal clearance
CCBs, nitrates, anticholinergics, α-adrenergic antagonists, prostaglandins, theophylline, sedatives
Medications that irritate already inflamed tissue
Aspirin, NSAIDs, bisphosphonates
Decide whether to avoid these medications on a case by case basis
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
Which non-prescription medications are effective in the management of GERD?
Antacids neutralize stomach acid to relieve heartburn
Best used “on-demand” for infrequent symptoms
Regular or frequent use a marker of uncontrolled GERD
H2-receptor antagonists (H2RAs)
Inhibit histamine binding on gastric parietal cell receptor
Help heal erosive esophagitis and improve symptoms
Best used “on-demand” for infrequent symptoms in patients with symptoms after stopping initial PPI therapy
Use when PPIs not tolerated or contraindicated
Use limited by tachyphylaxis
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
PPIs
First-line agents for patients with erosive disease or with typical esophageal symptoms
Irreversibly inhibit parietal cell proton pump
Most efficacious when taken 30 to 60 minutes before eating
More potent acid suppressors than H2RAs
Initial therapy: 8-week course of once daily PPI
Maintenance therapy indicated if GERD symptoms persist
Continued
When should clinicians consider prescription medications?
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
tLESR inhibitors (baclofen)
GABA-B agonist increases lower esophageal sphincter tone
Prokinetic agents (metoclopramide)
Promote gastric emptying
Mucosal protectant (sucralfate)
Binds to inflamed mucosa
Antidepressants (SSRIs, tricyclic antidepressants)
May modulate visceral pain sensation due to acid exposure
especially in hypersensitive patients
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
How should clinicians select from among available antireflux medications?
No real efficacy differences within same medication class
Modest superiority for esomeprazole vs. other PPIs
Dexlansoprazole can be dosed at any time of day
Immediate release omeprazole-sodium bicarbonate may improve nighttime gastric pH compared to other PPIs
Few data to support high- or double-dose of any PPI other than acute healing of esophagitis
Idiopathic side effects (diarrhea, constipation, headache) may occur with one PPI but not another
Pregnancy may affect medication selection
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
Complicated GERD
Erosive disease, stricture, or Barrett esophagus
Indefinite PPI maintenance therapy avoids relapse
Decreases risk of dysplasia development
How long should patients continue pharmacologic therapy for GERD?
Uncomplicated GERD
Consider maintenance therapy if symptoms recur
Make every attempt to taper and minimize medication use
Manage with intermittent or on-demand PPI therapy
Consider ‘step-down’ approach by using H2RAs on-demand
Balance symptom control against cost, inconvenience, and potential side effects of chronic PPI use
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
What are the adverse effects of long-term acid suppression therapy?
Gastric acid aids in vitamin and mineral absorption
PPIs may increase iron deficiency or pernicious anemia risk
PPIs may increase hip fracture risk
Gastric acid aids in destruction of ingested potentially pathogenic bacteria
PPIs may increase risk for enteric infections (C. difficile)
Pneumonia may be more common during sh-term PPI use
PPI + clopidogrel may increase cardiovascular risk
Long-term PPI use could predispose to intestinal metaplasia or gastric malignancy
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
When should clinicians consider surgical therapy for GERD?
Surgical anti-reflux therapy: laparoscopic fundoplication
Long-term treatment option with similar efficacy to medical Rx for some
Those with typical symptoms who respond to PPIs but wish to discontinue use
Those with continued symptoms / damage despite PPIs
Evidence doesn’t support surgery for other patients
Those with atypical symptoms or who don’t respond to PPIs
Those with Barrett esophagus who wish to prevent cancer
Bariatric surgery may be a treatment option for morbidly obese patients with GERD
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
Is it necessary to evaluate for Barrett esophagus periodically?
Estimated to occur in up to 10% with chronic GERD
Annual risk of esophageal adenocarcinoma is low (≈ 0.12%) even in patients with Barrett esophagus
Consider endoscopy for men >50 who have had GERD ≥5 yrs and who are overweight or have other risk factors
No role for periodic screening endoscopy in patients with uncomplicated GERD
No role for periodic screening endoscopy in patients with normal index endoscopy performed for above indications
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
How should clinicians manage patients once Barrett esophagus is present?
Periodic surveillance can lead to earlier cancer Dx
In absence of dysplasia, use endoscopy every 3-5 years
Continue PPIs
Document presence of absence of dysplasia
Risk of progression to adenocarcinoma 0.1% to 0.5% per patient-year for non-dysplastic Barrett esophagus
Risk of progression to adenocarcinoma 5%-20% for dysplastic tissue
Data support endoscopic eradication therapy with radio-frequency ablation for high- and low-grade dysplasia
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
How frequently should clinicians see patients with GERD and what are the components of good follow-up?
At least annually if chronically taking PPIs or H2RAs
Assess symptom character, frequency, and severity
Check for alarm signs
Provide counseling to reduce exacerbating factors
Taper medical therapy to lowest effective dose
Reassure patients that risk for developing complicated disease is very low in uncomplicated GERD
Even with continued symptoms of heartburn and reflux
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
When should clinicians consider gastroenterology referral for treatment of a patient with GERD?
Alarm symptoms develop in context of previously well-managed GERD
Patients are interested in anti-reflux procedures
Patients are at high risk of Barrett esophagus and adenocarcinoma
Patients have prior documented severe esophagitis or Barrett esophagus
Most gastroenterologists happy to assist in all aspects of care
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.
CLINICAL BOTTOM LINE: Treatment... Nonmedication treatment
Weight loss for obese persons Head-of-bed elevation for people with reflux at night Dietary changes not universally recommended
Medication treatment Initial Rx: PPIs once daily (30-60 mins before meal) for 8 wks For those responsive to PPIs, taper to lowest effective dose For those unable to taper or with significant erosive disease,
Barrett esophagus, or peptic stricture Hx: Continue PPIs H2RAs and antacids may be used for occasional symptoms Surgery is an effective option for some patients with GERD Refer for specialty evaluation when alarm symptoms develop